PMH

  • Appendicitis with appendix removal 2003
VOCAB/ACRONYMS

  • A&O x 3 – alert and oriented to person, place and time
  • t/o – throughout
  • B/L – bilateral
  • Romberg test – close eyes while standing.

OBSERVATIONS

Her husband adds that she:
  • has been more clumsy recently
  • trips very often
  • has a very low energy level
  • complains of feeling fatigued

TESTS ORDERED AND RESULTS

  1. Brain MRI – multiple diffuse plaques throughout the brain consistent with demyelination

SYMPTOMS/COMPLAINTS

  • Tingling and “strange sensations” in both legs and both hands
  • Symptoms have started two days ago but have occurred a couple times before in a little over a year that disappeared.
  • Sensations do not feel normal in both legs below the knees (states that it feels as if she is wearing socks when she is touched.)
  • Triceps and patellar reflexes are slightly elevated bilateral.
  • Patient has 20/50 vision B/L. She does not wear any corrective lenses and states she has never needed to.
  • Romberg test is positive
DIAGNOSIS

Multiple Sclerosis

RATIONALE FOR DIAGNOSIS
  • The patient's reoccuring tingling sensation in her hands and legs, her decrease capability in vision, and the MRI showing demyelination indicates that she has Multiple Sclerosis.




Complete the following for the disease you diagnosed

NAME OF DISEASE

Multiple Sclerosis

SIGNS AND SYMPTOMS OF DISEASE

  • Tingling and “strange sensations” in both legs and both hands
  • Symptoms have started two days ago but have occurred a couple times before in a little over a year that disappeared.
  • Patient has 20/50 vision B/L. She does not wear any corrective lenses and states she has never needed to.


HOW DISEASE IS DIAGNOSED (WHAT DIAGNOSTIC TESTS AND WHAT THEY WOULD SHOW)

Magnetic Resonance Imaging ( MRI) Scan - MRIs use computer generated radio waves and powerful magnetic waves to produce images of the body structures including tissues, organs, bones, and nerve. In this case, the brain and spinal cord of the patient was targeted for tests.

TREATMENT

Although a cure for multiple sclerosis does not yet exist, by coping with multiple sclerosis and its symptoms, those affected should still try to stay well.

  • Maintain proper physical fitness and diet.
  • Medication
    • Corticosteroids: These affect immunologic actions, such as inflammation (swelling) and immune responses associated with multiple sclerosis may help expedite the recovery (but not necessarily reduce the severity) from multiple sclerosis attacks.
    • Immune-modulating drugs: These decrease the ability of the immune cells to cause inflammation.
    • Immunosuppressants: These are stronger medications that also interfere with the function of the immune system and can reduce inflammation.
  • Acupuncture
  • Vitamin Supplements
  • Rehabilitation if necessary
  • Manage stress and emotions efficiently


PROGNOSIS AND COURSE OF DISEASE


The average life expectancy for someone with MS is 35 years after the symptoms begin. This represents a life expectancy of 95 percent of someone who does not have multiple sclerosis.

Most people with the disease can function effectively; however, a rare form of acute MS can be fatal within weeks.





WHAT IT’S LIKE TO LIVE WITH IT (FIND PICTURES AND VIDEOS FOR YOUR WIKI PAGE)